Rate and risk factors of inadequate endometrial tissues after endometrial sampling among Bhutanese women at the national referral hospital of Bhutan: a cross-sectional study.

INTRODUCTION: Women presenting with abnormal uterine bleeding needs careful and thorough assessment including ultrasound examination of endometrium and histopathological assessment of the endometrial tissues. The objective of this cross-sectional study was to determine the rate and the factors associated with inadequate endometrial tissues after endometrial sampling using MedGyn® pipette among Bhutanese women at the colposcopy clinic, Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Bhutan. METHODS: This cross-sectional study was conducted at the colposcopy clinic, JDWNRH, Thimphu between October, 2021 and March, 2022. Women included in this study underwent endometrial sampling using MedGyn® pipette without anesthesia as an office procedure. Data were collected using an interviewer-administered questionnaire and results extracted into a structured pro forma. The histopathology reports were extracted from the Department of Pathology and Laboratory Medicine, JDWNRH using the unique Bhutanese citizenship identity card number of the study participants. RESULTS: Inadequate endometrial tissues were noted in 27% (33 out of 122 cases). Among 89 patients with an adequate endometrial tissue, histologic results were normal in 30 (33.7%), benign pathology in 22 (24.7%), atrophy in 10 (8.2%), and hyperplasia in 27 (30.3%). In a univariate analysis, menopausal state (OR 1.6, 95% CI 0.708-3.765), overweight and obese (OR 1.6 95% CI 0.640-3.945), unemployed (OR 1.7, 95% CI 0.674-1.140), nulliparous (OR 1.7, 95% CI 0.183-15.816), primipara (OR 5.1, 95% CI 0.635-40.905) and use of hormonal contraception (OR 2.1, 95% CI 0.449-10.049) were associated with increased risk of inadequate endometrial tissues. On multivariate regression analysis, nulliparity (OR 1.1, 95% CI 0.101-12.061), overweight and obesity (OR 1.4, 95% CI 0.490-3.917), use of hormonal contraceptives (OR 2.2, 95% CI 0.347-13.889), and junior surgeons (OR 1.1, 95%CI 0.463-2.443) were found to be associated with inadequate endometrial tissues. However, the above associations were not statistically significant (p > 0.05). CONCLUSION: The rate of inadequate endometrial tissue following endometrial sampling using MedGyn® pipette was 27.0%. Factors associated with an increased risk of inadequate endometrial tissue after endometrial sampling were menopausal state, overweight and obese, unemployed, nulliparous, primipara and use of hormonal contraception.

Factors associated with postoperative nausea and vomiting after laparoscopic cholecystectomy at the National Referral Hospital, Bhutan: a cross-sectional study.

INTRODUCTION: Postoperative nausea and vomiting (PONV) are common distressing symptoms experienced after laparoscopic cholecystectomy. We report the rate, and the factors associated with postoperative nausea and vomiting, the patterns of prophylactic antiemetic prescription, and the anesthetic techniques used among patients who underwent laparoscopic cholecystectomy at the Jigme Dorji Wangchuck (JDW) National Referral Hospital, Bhutan. METHODS: A cross-sectional study was conducted at the JDW National Referral Hospital, from January to December 2018. All the patients who underwent laparoscopic cholecystectomy under general anesthesia were included in the study. The demographic variables, premedication, induction agents, muscle relaxants, inhalational agents for maintenance, opioid and adjuvant analgesics, the reversal agents used, and the occurrence of PONV within 24 h were recorded. Data were analyzed using SPSS (version 23). Continuous variables were compared using a t-test or Mann-Whitney test, categorical variables were tested using chi-square or Fisher's exact tests. Binary logistic regression analysis was performed to determine the factors associated with postoperative nausea and vomiting. RESULTS: 190 patients underwent laparoscopic cholecystectomy under general anesthesia. The rate of PONV after laparoscopic cholecystectomy was 31.1% (59/190). Over half (53.7%, 102/190) of the study population were within 21-40 years of age, over 80% (157/190) were female, and 2/3rd were overweight and obese. The most frequently used premedication was ranitidine (39%, 34/87) and metoclopramide (31%, 27/87). More than half (57.4%, 109/190) of the patients received morphine as an opioid analgesic before induction. Sodium thiopentone was a commonly used induction agent (65.8%, 125/190). Succinylcholine and atracurium were mostly preferred muscle relaxants. Isoflurane and air were the most used inhalational anesthetic agents for the maintenance of anesthesia. Ondansetron was the most preferred anti-emetics during the intraoperative period. Previous history of motion sickness (OR 5.8, 95%CI 2.9-11.2, p < 0.001), and use of sodium thiopental (OR 4.1, 95%CI 1.9-9.1, p < 0.001) were independent risk factors for PONV. The use of antiemetics (OR 0.1, 95%CI 0.0-0.4, p = 0.002), propofol (OR 0.2, 95%CI 0.1-0.5, p < 0.001), adjuvant analgesic paracetamol (OR 0.4, 95%CI 0.2-0.8, p = 0.026), and adequate hydration with IV fluids (OR 0.9, 95%CI 0.9-1.0, p = 0.042) were preventive factors for PONV. CONCLUSION: The rate of PONV after laparoscopic cholecystectomy was high. History of motion sickness and use of sodium thiopental for induction were independent risk factors of PONV. The use of multimodal prophylactic antiemetics was robust and superior to monotherapy in preventing PONV. This finding re-emphasizes the need for risk stratification and appropriate use of antiemetics and anesthetic agents to prevent PONV.

Evaluation of the diagnostic performance of colposcopy in the diagnosis of histologic cervical intraepithelial neoplasia 2+ (CIN2+).

BACKGROUND: Colposcopy is a tool for triaging screen positive women regardless of method used for cervical cancer screening. The objective of this study was to evaluate the diagnostic performance of colposcopy in the diagnosis of histologic cervical intraepithelial neoplasia 2+ (CIN 2+) at Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Thimphu, Bhutan. METHODS: This cross-sectional study was conducted from March 2021 to August 2021 among 299 women who availed colposcopy services at the colposcopy clinic of JDWNRH, Bhutan. Women included in this study were either screen positive (Pap smear) or were suspected to have invasive cancer; they underwent colposcopy and a cervical biopsy irrespective of colposcopy impression. This histopathologic assessment was considered as the gold standard test for the diagnosis of cervical intraepithelial neoplasia (CIN) or invasive cancer. RESULTS: The mean age of the study participants was 43 years (ranges, 25-76 years). The sensitivity, specificity and accuracy of senior colposcopists to diagnose histologic CIN 2+ were 80.0% (95% CI 59.30, 93.17), 71.07% (95% CI 62.13, 78.95), and 72.60% (95% CI 64.61, 79.65), and for junior colposcopists were 59.46% (95% CI 42.10, 75.25), 76.72% (95% CI 67.97, 84.04), and 72.55% (95% CI 64.76, 79.45) respectively. The overall sensitivity, specificity, and accuracy of colposcopy to diagnose histologic CIN 2+ were 66.67% (95% CI 53.66, 78.05), 73.73% (95% CI 67.63, 79.23), and 72.24% (95% CI 66.79, 77.24) respectively. CONCLUSIONS: In this study, the senior and junior colposcopists had a comparable colposcopic accuracy to diagnose histologic CIN 2+, whereas senior had a higher sensitivity but a lower specificity than junior colposcopists.

Massive ascites following spontaneous vaginal delivery in a woman with preeclampsia-a diagnostic and management challenges in a low resource country: A case report.

INTRODUCTION AND IMPORTANCE: Hypertensive disorders of pregnancy, including preeclampsia, causes major pregnancy associated morbidity and mortality. Massive ascites is a rare complication in a severe preeclampsia. This case report high lights the importance of obstetrician being aware of such complications of severe preeclampsia, and avoid non-therapeutic interventions such as exploratory laparotomy. CASE PRESENTATION: A 39-year-old woman from remote village of Bhutan with severe preeclampsia had spontaneous vaginal delivery in the ambulance at 34+6 weeks of gestation enroute to a tertiary care hospital. In the postpartum period, she had a massive ascites, and she underwent exploratory laparotomy. DISCUSSION: Ascites in severe preeclampsia is a rare complication. Diagnosis and management of such a rare condition is challenging in a resource constraint setting. In addition, prevalence of tuberculosis and gynecological malignancies in our setting prompts obstetricians to perform an invasive procedure such as exploratory laparotomy in view of excluding these conditions. CONCLUSION: This case report highlights the importance of obstetricians to be aware of the possibility of ascites in preeclampsia which may be managed medically, without the need for surgical interventions.

Population-level cancer screening and cancer care in Bhutan, 2020-2023: a review.

Screening of cancers is an important intervention in reducing the incidence and mortality related to cancers. Bhutan is one small country that is witnessing an increasing incidence and mortality related to cancers. The government implemented a time-bound population-level screening for gastric, cervical and breast cancers from 2020 to 2023 with an overall coverage of 91.2% of the eligible population. Among 370,225 individuals screened for H pylori, 32.4% tested positive; among 53,182 who underwent upper gastrointestinal endoscopy and biopsy, 255 (0.07%) had gastric cancer. Among 10,749 tested for HPV DNA, 9.3% were positive; among 9887 evaluated with colposcopy and biopsy, 154 (0.13%) had cervical cancer. For breast cancer screening, 72,283 underwent clinical breast examination, 845 mammography and cancer was detected in 73 (0.10%) individuals. In this article, we review how Bhutan implemented a population-level cancer screening programme with on boarding of multiple stakeholders and the participation of people across all districts.

Intimate partner violence with vaginal insertion of a partial chili pod (Capsicum annuum): A case report.

A case of intimate partner violence (IPV) with vaginal insertion of an irritant foreign body, chili pod of Capsicum annum, in a 36-year-old woman. She presented with severe burning sensation in the lower abdomen and vulva. This highlights the unique role of gynecologists in the recognition and treatment of IPV.

Coincidental finding of a giant bladder calculus and squamous cell carcinoma of bladder: A case report.

Chronic irritation of bladder by urinary bladder calculus is a known risk factor for bladder cancer. The use of Wrigley's obstetrical forceps in general surgical practice is a rare event. Herein, we report a case of a giant urinary bladder calculus which was removed by Wrigley's obstetrical forceps during open cystolithotomy. The bladder biopsy showed squamous cell carcinoma of the bladder. With this report, we aim to create an awareness among surgeons about the role of the Wrigley's obstetrical forceps during open cystolithotomy, and the role of taking urinary bladder biopsy from chronically inflamed/unhealthy sites.

Stomach Cancer Screening Services of Bhutan.

Stomach cancer is a common public health problem in South East Asia including Bhutan. Chronic infection with Helicobacter pylori is regarded as the principal cause of stomach cancer. Herein, we present the incidence of stomach cancer in Bhutan for eight years (from 2014 to 2021). We also discuss the steps taken for the prevention and early detection of stomach cancer.

Incidental diagnosis of squamous cell carcinoma transformation in mature cystic teratoma of the ovary: A case report and review of literature.

Malignant transformation in a mature cystic teratoma of the ovary is a rare complication. Herein, we report a case of a 62-year-old woman who was diagnosed with squamous cell carcinoma in a mature cystic teratoma of the ovary in the histopathology examination. This case report highlights the importance of suspecting malignant transformation in an elderly woman with a large mature cystic teratoma of the ovary with a thickened wall so that proper surgical and adjuvant treatments are planned.

Post-cesarean severe sepsis and uterine wound disruption presenting as abdominal wound abscess and peritonitis: A case report.

With increasing rate of cesarean section in Bhutan, the complications are expected to rise. Uterine scar dehiscence is one of the immediate complications of cesarean section, which has high morbidity and mortality. Herein, we report a case of uterine wound dehiscence with pelvic abscess following cesarean section, who presented with paralytic ileus and surgical site infection. There should be high degree of suspicion of uterine scar dehiscence with pelvic abscess in cases of paralytic ileus and surgical site infection following cesarean section, which does not improve with medical management. What made this case unusual was presentation of uterine scar dehiscence with abdominal wound sepsis. Prompt diagnosis with appropriate treatment is required to prevent morbidity and possible maternal mortality.

Jejunal perforation after a trivial trauma: A case report.

Jejunal perforation after a trivial trauma is a rare event. We present a case of a 23-year-old man, a truck driver who suffered jejunal perforation following a jump from the Indian jumbo truck, approximately 2 m height from the ground. This case report highlights the importance of careful evaluation of a symptomatic patient after a trivial injury, and the challenges faced by surgeons in the low recourse-setting.

Uterus didelphys with double vagina diagnosed during third cesarean section: A case report.

Uterus didelphys is a rare uterine anomaly. It is associated with fetal breech presentation, preterm delivery, and cesarean section. Longitudinal vaginal septum may be associated with uterus didelphys, which may cause dyspareunia and labor obstruction. We report a case of 28-year-old woman whose uterus didelphys and longitudinal vaginal septum were diagnosed during third cesarean section. This case report highlights the importance of routine examination of adnexal structures during cesarean section, so that any unsuspected pathologies in the uterus, tubes, and ovaries are diagnosed.

Setting up minimal invasive surgery services in gynecology in a resource-limited setting: an experience from Bhutan.

OBJECTIVE: To describe the clinical profile of minimal invasive procedures performed in gynecology at the national referral hospital in Bhutan. A review of such procedures performed in gynecology was needed to assess the baseline information and generate our own experience. We conducted a descriptive study with a review of hospital records of minimal invasive procedures performed from 1st January to 31st December 2020 at the Department of Gynecology. Data were extracted into a structured pro forma. Descriptive statistics were used to express the results. RESULTS: The mean age of the patients was 33.9 ± 8.6 years of which the maximum was in the age group 25-34 years. 28 (17.5%) and 132 (82.5%) patients underwent emergency and elective procedures respectively. 142 (88.8%) and 18 (11.2%) patients underwent laparoscopic and hysteroscopic procedures respectively. Ovarian cystectomy was the most commonly performed procedure. The median operating time was 100 min (IQR 62.5-157.5). The overall complication rate was 2.5%. The median postoperative length of hospital stay was 24 h (IQR 3-24). Using our data and experience, we recommend a new health policy to recognize MIS in gynecology as a subspecialty and strengthen the existing service in gynecological MIS.

Maternal sirolimus therapy and fetal growth restriction.

Fetal growth restriction associated with continued maternal sirolimus therapy in pregnancy has not been reported. We hereby present a case of maternal sirolimus therapy resulting in fetal growth restriction and propose a multi-hit model. This hypothetic model is based on inhibition of mTOR signaling pathway and epigenetic modulation. This case report adds to the paucity of literature on continued monotherapeutic maternal sirolimus in pregnancy and its adverse fetal effects.

Scrub typhus in pregnancy presenting with permanent hearing loss: A case report.

As clinicians, we need to be vigilant about these rare and atypical presentations given the endemic nature of scrub typhus in southern belt of the country. Timely diagnosis and appropriate treatment is the key aspect to prevent further complications.

Indications and factors associated with cesarean section in Bhutan: A hospital-based study.

OBJECTIVE: To investigate the factors associated with cesarean section (CS) in Bhutan. METHODS: This was a cross-sectional study, using the retrospective data from the birth registers maintained in comprehensive emergency obstetric care centers for the year 2018. The data were entered in excel 2013 and analyzed using STATA 13. Multiple logistic regression was used to understand the factors associated with CS in Bhutan. RESULTS: The rate of CS in Bhutan was 18.7%. The indications for CS were previous CS, fetal distress, prolonged labor, and failed induction. The factors associated with CS were maternal age over 25 years, male child, women with smaller number of living children, multiple pregnancy, and gestation over 40 weeks. In addition, mothers delivering in Samtse Hospital and Central Regional Referral Hospital had higher odds of CS. CONCLUSION: In Bhutan, CS was commonly performed for mothers with previous CS, fetal distress, and prolonged labor. Increasing maternal age, multiple pregnancy, and postdated pregnancy and those with one child, or none, were more likely to undergo CS. To reduce the CS rate, Bhutan should focus on decreasing the primary CS rate as well as preventing over-diagnosis of prolonged labor by focusing on the partograph.